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  • Telemedicine and Consent Form

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  • Social History:

  • Introduction to Telehealth

    Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.

  • CONSENT FOR TELEHEALTH CONSULTATION

    1.     I understand that I am voluntarily engaging in a telemedicine consultation with HIGH ALTITUDE MOBILE PHYSICIANS

    2.     I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

    3.     I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

    4.     I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

    5.     I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

    6.     I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with HIGH ALTITUDE MOBILE PHYSICIANS and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.

    7.     I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through HIGH ALTITUDE MOBILE PHYSICIANS will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

    8.     Telemedicine services offered through HIGH ALTITUDE MOBILE PHYSICIANS are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.

    9.     To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

    By signing this form, I certify:

    ·       That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.

    ·       That I have had the opportunity to ask questions and have had them answered to my satisfaction.

    BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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    Must be signed by legal guardian if patient is under age 18 or requires a legal guardian:

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  • MEDICARE OPT OUT PRIVATE CONTRACT


    • I, Leslie Shook and Danielle Shook (High Altitude Mobile Physicians), have been excluded from Medicare under §§1128, 1156 or 1892 of the Act.
    • I, the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner.
    • I, the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.
    • I, the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare.
    • I, the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
    • I, the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
    • The expected or known effective date and expected or known expiration date of the opt-out period is April 1, 2018 through April 1, 2026.
    • I, the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
    • This contract cannot be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)
    • I, the beneficiary or the beneficiary’s legal representative will receive or have received a copy (a photocopy permissible) of this contract, before items or services are furnished to me under the terms of this contract.

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  • Provider Assessment

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  • Patient Education:

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